New to helping someone in New Jersey?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
New Jersey law gives you an internal appeal with the carrier first in most cases, then a right to external review through the Independent Health Care Appeals Program (IHCAP) administered by the Department of Banking and Insurance (DOBI).
For steps that work in every state, read these general guides first, then return here for New Jersey rules:
What is different in New Jersey?
- Get Covered New Jersey: The state's official Marketplace at GetCoveredNJ. Major 2026 carriers include Horizon BCBSNJ, AmeriHealth, Oscar, Ambetter from WellCare of New Jersey, and UnitedHealthcare. Availability varies by county.
- Prior authorization (ETPAA, 2023): P.L. 2023, c.296 (codified at N.J.S.A. 17B:30-55) sets ePA drug deadlines (24 hours urgent / 72 hours non-urgent), outpatient PA within 9–12 days, urgent determinations within 72 hours, missed deadlines → deemed authorized; chronic PA valid 180 days.
- Internal appeals: File within 180 days of an adverse utilization management (UM) determination (DOBI UM appeals Q&A); standard decisions often within 30 days, expedited within 72 hours when urgent.
- External review (IHCAP): Request within four months of the final internal UM denial; 45 calendar days for standard IURO review, 48 hours when expedited (DOBI — IHCAP).
- NJ FamilyCare (Medicaid): MCO appeal first (often 60 days), then DOBI external review for UM disputes or a Medicaid fair hearing with DMAHS—separate from commercial IHCAP rules.
Who is in charge of your plan?
- DOBI: External review (IHCAP), consumer help, PA oversight — nj.gov/dobi. Consumer assistance: 800-446-7467 or 609-292-7272. IHCAP help: 888-393-1062 or 609-777-9470.
- U.S. Department of Labor: Many self-funded employer plans.
- DMAHS — Medicaid fair hearings: After MCO appeal resolution for NJ FamilyCare Plan A and certain other categories — see your Notice of Resolution.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.